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Careplan

Balance Impairment, Pediatric

Dec.17.2019

Balance Impairment (Pediatric Inpatient)

Clinical Description

  • Care of the hospitalized child experiencing an inability to safely or comfortably maintain upright control of the body’s center of gravity relative to the base of support in the given environment.

Key Information

  • Balance is a complex process involving interactions between multiple body systems, including musculoskeletal, neurologic and sensory systems, such as vestibular, visual and somatosensory systems. Assessment and treatment should address the multifactorial components of balance.
  • Deficits in attention, judgment, memory and cognition directly influence balance abilities, as well as hinder motor learning processes needed to learn or relearn balance skills.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Improved Balance and Postural Control

B. Patient, family or significant other will teach back or demonstrate education topics and points:
  • Education: Overview
  • Education: Self Management
  • Education: When to Seek Medical Attention

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity, congenital anomaly
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • child and family/caregiver:
      • health literacy
      • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

Balance Impairment

Signs/Symptoms/Presentation

  • dizziness
  • hearing impairment
  • history of fall
  • postural control impaired
  • stumbling
  • unsteady gait
  • vertigo
  • visual impairment
  • wide base of support for age

Problem Intervention

Optimize Balance and Safe Activity

  • Evaluate functional balance skills including postural control, static and dynamic balance; consider child’s age, developmental level and ability to follow directions.
  • Screen for and address underlying impairments, such as muscle weakness, sensorimotor, cognitive and postural control deficits.
  • Encourage independent functional status while providing level of assistance needed for safety.
  • Recommend and facilitate environmental modifications to promote independence and safety, such as grab bars, bath seat; consider a home assessment.
  • Train in and reinforce use of appropriate orthoses, adaptive equipment or assistive devices (e.g., ankle foot orthosis, adaptive seating system, scooter).
  • Facilitate safe surroundings; keep needed items within reach, such as call light and personal belongings.
  • Provide a safe, barrier-free, uncluttered environment that promotes optimal level of function; ensure adequate lighting, especially at night.
  • Facilitate therapeutic interventions, such as balance training, muscle strengthening, structured play, trunk training, virtual reality and tai chi, yoga or Pilates exercise.
  • Address sitting balance impairments with interventions, such as supportive seating, positioning devices and therapeutic exercise.

Associated Documentation

  • Activity Management
  • Adaptive Equipment Use
  • Safety Promotion/Fall Prevention
  • Self-Care Promotion

Education

CPG-Specific Education Topics

Overview

  • description

  • signs/symptoms

Self Management

  • activity

  • assistive/adaptive devices

  • home safety

  • prevent skin breakdown

  • provider follow-up

  • rehabilitation therapy

When to Seek Medical Attention

  • unresolved/worsening symptoms

General Education Topics

General Education

  • admission, transition of care

  • orientation to care setting, routine

  • advance care planning

  • diagnostic tests/procedures

  • diet modification

  • opioid medication management

  • oral health

  • medication management

  • pain assessment process

  • safe medication disposal

  • tobacco use, smoke exposure

  • treatment plan

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

Population-Specific Considerations

Age-Related

  • Younger children have a stronger reliance on visual input to make postural corrections. Children with visual impairments may demonstrate greater balance impairment deficits.
  • The causes of balance problems can be difficult to identify in children; impairments are often overlooked, as symptoms might be attributed to developmental stage.

References

  • (2015). Alexander, M. A.; Matthews, D. J.; Murphy, K. P (Eds.), Pediatric rehabilitation: Principles and practices. New York: Demos Medical Publishing. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Behm, D. G.; Muehlbauer, T.; Kibele, A.; Granacher, U. Effects of strength training using unstable surfaces on strength, power and balance performance across the lifespan: A systematic review and meta analysis. Sports Medicine. 2015;45(12), 1645-1669. [Metasynthesis,Meta-analysis,Systematic Review]
  • Case-Smith, J.; O'Brien, J. C. (2015). Occupational therapy for children and adolescents. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Cincinnati Children's Hospital Medical Center. (2014). Best evidence statement (BESt). The use of yoga to improve strength, balance, and coordination. Source[Quality Measures,Clinical Practice Guidelines]
  • Gebel, A.; Lesinski, M.; Behm, D. G.; Granacher, U. Effects and dose-response relationship of balance training on balance performance in youth: A systematic review and meta-analysis. Sports Medicine. 2018;48(9), 2067-2089. doi:10.1007/s40279-018-0926-0 [Metasynthesis,Meta-analysis,Systematic Review]
  • Ghislieri, M.; Gastaldi, L.; Pastorelli, S.; Tadano, S.; Agostini, V. Wearable inertial sensors to assess standing balance: A systematic review. Sensors. 2019;19(19), 4075. doi:10.3390/s19194075 [Metasynthesis,Meta-analysis,Systematic Review]
  • Hornsby, E.; Johnston, L. M. Effect of Pilates intervention on physical function of children and youth: A systematic review. Archives of Physical Medicine and Rehabilitation. 2019; doi:10.1016/j.apmr.2019.05.023 [Metasynthesis,Meta-analysis,Systematic Review]
  • Howard, M. C. A meta-analysis and systematic literature review of virtual reality rehabilitation programs. Computers in Human Behavior. 2017;70, 317-327. doi:10.1016/j.chb.2017.01.013 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Huang, H. W.; Nicholson, N.; Thomas, S. Impact of tai chi exercise on balance disorders: A systematic review. American Journal of Audiology. 2019;28(2), 391-404. doi:10.1044/2018_AJA-18-0115 [Metasynthesis,Meta-analysis,Systematic Review]
  • Moral-Munoz, J. A.; Esteban-Moreno, B.; Herrera-Viedma, E.; Cobo, M. J.; Pérez, I. J. Smartphone applications to perform body balance assessment: A standardized review. Journal of Medical Systems. 2018;42(7), 119. doi:10.1007/s10916-018-0970-1 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Palisano, R. J.; Orlin, M. N.; Schreiber, J. (2017). Campbell's physical therapy for children. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Sibley, K. M.; Beauchamp, M. K.; Van Ooteghem, K.; Paterson, M.; Wittmeier, K. D. Components of standing postural control evaluated in pediatric balance measures: A scoping review. Archives of Physical Medicine and Rehabilitation. 2017;98(10), 2066-2078. doi:10.1016/j.apmr.2017.02.032 [Metasynthesis,Meta-analysis,Systematic Review]
  • Umphred, D. A.; Lazaro, R. T.; Roller, M. L.; Burton, G. U. (2013). Umphred's neurological rehabilitation. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Wang, J.; Xu, J.; An, R. Effectiveness of backward walking training on balance performance: A systematic review and meta-analysis. Gait & Posture. 2019; doi:10.1016/j.gaitpost.2019.01.002 Source[Metasynthesis,Meta-analysis,Systematic Review]
  • Wälchli, M.; Ruffieux, J.; Mouthon, A.; Keller, M.; Taube, W. Is young age a limiting factor when training balance? Effects of child-oriented balance training in children and adolescents. Pediatric Exercise Science. 2018;30(1), 176-184. doi:10.1123/pes.2017-0061 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]

Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.